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is Technologies Soil Recycling Non-Hazardous Soils Date of Shipment: Responsible for Payment: Transporter Truck#: Facility# Given b TPS: r ; Y .� Y , Load p - Generator's Name and Billing Address: Geneeator's Phone#: Generator's US EPS ID No. Person to Cont,et: ( r I, i,_, F.AN#: Customer ACCount dumber with TPS: Consultant's dame and Billing address: Consultant's Phone r*: t. /:} { 6 i_ l:rr, i',r.ri.?,_. i. C':1 ' Person to Contact: _ _ �•_f r' i. i .L'_ , ;a„ FAX#' Customer account Ntunber with TPS: 'Generation Site{Transport troml: (mmne&address) Site Phone#: BTEX Levels Wt-`:''-. Ke F t'_1:_ .1-ri I! :r' Person to Contact: TPH C Lel eLs Fa`C#: AVG. CA fi Levels VDesignated Facility(Transport to): (same&address) Facilit•Phone#: Facilit-Permit Numbers 4fi_,-t rt•_ Person to Contact: _ v O FAX#: t...A `?-A.Q0 L tl. :=:j t'l G Transporter Name and Mailing Address: Transporter's Phone 0: Transporter's US EPA ID No.: C rte- � �--44 �- �' c� '- V Persovo Contact: Transporter's DOT No.: FAX# Customer Account Number with TPS- Deseflption of Soil Moisture Content Contaminated by: Approx.Qty: Description of Delivery Gross Weight Tare Welght Net Weight 0-10% ❑ Gas ❑ Sand C3 Organic] Clay ❑ Other :110-20% ❑ Diesel U 20%-over❑ Other ❑ Sand ❑ Organic❑ 0-10% ❑ Gas ❑ Clay ❑ Other ❑ to- Diesel ❑ 24/-over❑ Other '❑ List any exception to items listed above. Generator's and/or consultant's certification: I/We certify that the soil referenced herein is taken entirely from those soils described in the Soil Data . Sheet completed and certified by me/us for the Generation Site shown above and nothing has been added or done to such soil that would alter it in any way, Print o ype Name: - Generator Consultant Sigp:at`re and date: / �% Month Day Year oTransporter's certtfrcation. I/We acknowledge receipt of the soi!dQserlSed a oae and certify that such soil is being delivered in exactly the same' condition as when received. I/We further certify that this soil is being directly transported from the Generation Site to the Designated Facility without off-loading,adding to,subtracting from or in any way delaying delivery to such site. Print or Type Name: Signature and date: ' S^a - Month Day Year 711 1, Discrepancies: i V s Q Recycling Facility certifies the receipt of the soil covered by this manifest except as noted above: :i., Print or Type Name: Si rWi gnature and date: ,g rc C G- =.YAi l7 COi Io!J_1Ai 1 S COPY